MEDICARE: TINA C BRYANT PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	KY1307	KY

General Provider Information

NPI Number	:	1093014094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA C BRYANT PH.D.

Provider Business Mailing Address
First Line	:	2220 EXECUTIVE DR STE 103
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40505-4871
Country	:	US
Telephone Number	:	859-963-6388
Fax Number	:

Provider Business Practice Location Address
First Line	:	2220 EXECUTIVE DR STE 103
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40505-4871
Country	:	US
Telephone Number	:	859-963-6388
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2011
Last Update Date	:	02/01/2012

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